Improving our practice

I think about being efficient and effective in my therapeutic relationship, knowing that the client benefits greatly from a solid therapeutic relationship, and it is my job as a practitioner to build it.

When someone is talking to me about their issues, I use “accurate empathic reflections”, usually complex ones, instead of questions. Reflections are statements (not questions) and they come in two main categories: simple and complex. The simple reflection mirrors precisely or very closely what the person in question (client, patient, user, etc.) has said, with no additional information. The complex reflection is also a statement but has something significant added in an attempt at getting at what the person means by what they say.

Reflections vs. questions

Reflections are emotionally connected responses to what the person has said; a heart-to-heart communication. Questions, on the other hand, are generated by the questioner’s agenda and may, or may not, be of interest to the client, more like, head-to-head.

Questions may in fact direct clients away from their concerns and toward our own, thereby both pulling at the fabric of the client-centred therapeutic alliance in an unhelpful way and misdirecting the conversation which will eventually have to be re-oriented back toward the client’s interest. Reflections, on the other hand, often “activate” our clients, getting them to reflect more deeply and moving them closer to change, a solution. I suspect that is because the person receiving the reflection then internally and silently compares it with what they thought they originally said. When we rely on questions, this opportunity is lost. Clients usually answer the questions politely but are often less connected with this direction, as our agenda may not be following their active line of thought, leaving them not fully engaged.

A few helpful ways to create helpful complex reflections

The easiest way to create a helpful complex reflection is to catch a passing closed question and transform it into a reflection. For example, “You’re happy about that?” (question created by rising intonation) can be transformed simply by bringing the voice down at the end, indicating a period rather than a question mark with a descending intonation, thus, “You’re happy about that.” If we have a tendency to use that rising intonation, called upspeak, we can imagine the sentence written out with a period at the end to help us bring our voice down at the end. In MI, this is referred to as a spoiled reflection. Many closed questions can be transformed in this manner.

Another way is for us to silently ask ourself the question that is distracting us, then silently answer it as best as we can (posing a hypothesis). and stating that hypothesis aloud in the second person, that is, starting with “You…”. That too, will become a complex reflection. For example, if we’re burning with the question of what they want from us, we might say, “You’d like me to help you find your way through this situation.”

Finally, we can synthesize the information (silently, in our minds) as if explaining what is happening with the client to a third person. Then we restate the distillation in the second person (grammatically speaking) and it becomes a complex reflection. So, if the client has been talking about the difficulty they are having with their partner, and saying that their partner doesn’t seem to want to spend time with them, doesn’t pay attention when they speak, and they haven’t had sex in weeks, we might imagine explaining to someone that “The client is struggling with finding intimacy with their partner and they would like to have more and better contact.” With grammatical transformation from the third person to the second person, this becomes the complex reflection that you state to your client: “You are struggling with finding intimacy with your partner and you would like to have more and better contact.”

Even if they reject the statement, the clients usually correct us in a helpful way. For example, a full rejection to the statement, “You aren’t willing to try the new treatment because you don’t want to go through the paperwork again,” might sound like this: “No it isn’t that. I don’t want to try that new treatment because I’m too tired to jump through all the insurance company’s hoops again to get it covered. I don’t want to try that new treatment because I don’t think it will work.” A partial rejection might sound like this: “Right, it isn’t that I don’t want to try that new treatment; I am just too tired to jump through the insurance company’s hoops.”

In either case, the person must reflect on what the practitioner has just said. This can often be seen in the person’s eyes and other non-verbal behaviour and is what I call “the hamster running”. The practitioner is encouraged to let the “hamster” run its course uninterrupted, as the person is very likely to elaborate their thoughts in the silent space.

In both of these cases, the person recognizes our attempt at understanding them (empathy), is actively involved in the conversation, and brings a refinement or precision to their – and our – understanding by correcting or adding to what we reflected. It is this to which I refer when I use the word “accurate”. The person helps us to gain a more truthful perception. While practitioners worry about not being accurate or “making a mistake”, it is unusual that the person won’t feel comfortable correcting us. Usually, our clients are very willing to bring clarity to their thoughts and share them with us. The important thing after a client’s correction is to let go of “our” direction and go in the one in which the client is leading us. The person concerned often reports feeling “heard and understood”, which we use as our working definition of empathy. Empathy, according to the research, is a fundamental component of a good therapeutic relationship.

Does this reflection on reflecting help you reflect on your MI practice?